WAHB New Client Enrollment Form

NEW CLIENT/PATIENT FORM

Welcome to Wickham Animal Hospital & Boarding! We look forward to serving you and your pets!
Have you ever brought a pet to Wickham Animal Hospital & Boarding before?*

YesNo
Owner's Name*

First NameLast Name
E-mail*
example@example.com
Main Contact Number:*
Phone Number Type
Secondary Contact Number:
Phone Number Type
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
How Would You Prefer To Be Contacted?*

Phone CallTextEmail
Is There a Spouse/Partner/Family Member Who Should Be Listed On Your Account?

YesNo
Spouse/Partner/Family Member Name

First NameLast Name
Please tell us how the above person is related to you so we can refer to your relationship appropriately.
Relationship Type
Spouse/Partner/ Family Member Contact Number:
Is there anyone else (besides above listed contacts) who should be listed on your account, who has ongoing permission to make medical decisions for your pet(s)?

YesNo
Emergency Contact:

First NameLast Name
Relationship
Contact Number

CLIENT POLICY & PROCEDURES

We want you to be aware of and understand the following policies and procedures for all clients.
We Love Social Media! Do we have your permission to post pictures of your pet(s), you and your pet(s) and/or your pet(s) and our team on Facebook, Instagram, Twitter, www.wickhamanimalhospitalandboarding.com and any other marketing and/or other social media outlets we may choose to use?*

NoYes (By selecting this option you grant Wickham Animal Hospital & Boarding, its representatives, and employees the right to take photographs and/or videos of you and/or your pet(s) and to copyright, use, and publish the same in print and/or electronically. You also grant Wickham Animal Hospital & Boarding the right to use such photographs and/or videos of you and/or your pet(s) with or without your name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and web content)
Wickham Animal Hospital & Boarding uses email, text and our own hospital app for communications regarding our patient's reminders for health care needs. Do we have your permission to contact you via email, text and/or our app regarding these reminders? *

YesNo
FINANCIAL POLICY:

Our office accepts Visa, Mastercard, Discover, and American Express. We also accept cash and checks (only with verification of valid drivers license or other ID at time of payment).

Full payment is due at the time of service. This includes any charges/fees agreed to by my authorized proxy. Our team is happy to provide any client with a written treatment plan prior to services being rendered. Your signature below indicates your agreement with these policies.
TREATMENT CONSENT:

By signing this document, I hereby certify that I am the lawful owner, or authorized agent, of all listed pets and that I have the authority to execute this consent. I freely give permission to the employees of Wickham Animal Hospital & Boarding to perform treatment on my pet(s) as recommended by the supervising veterinarian. I assume responsibility for all charges incurred in the care of this animal. My signature below also indicates that I am over 18 years of age. I understand that ALL FEES ARE DUE IN FULL AS SERVICES ARE RENDERED.
Signature*

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NEW CLIENT/PATIENT FORM

CLIENT POLICY & PROCEDURES